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Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 812-817

Nutrition in critically Ill pediatric patients: a systemic review

1 Department of Pediatrics, Faculty of Medicine, Sers Al-Lyan Hospital, Sers Al-Lyan, Menoufia, Egypt
2 Department of Pediatrics, Sers Al-Lyan Hospital, Sers Al-Lyan, Menoufia, Egypt

Date of Submission15-Jan-2018
Date of Acceptance06-Mar-2018
Date of Web Publication17-Oct-2019

Correspondence Address:
Hanem R M Ghetas
Sers Al-Lyan Hospital, Menoufia 32717
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_2_18

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The study aimed to review the different types of nutrition in critically ill pediatric patients.
Data sources
Medline databases (PubMed, Medscape, Science Direct, EMF-Portal, Google Scholar) and all materials available in the Internet from 2001 to 2014 were searched.
Study selection
The initial search presented 150 articles of which 50 met the inclusion criteria. The articles studied the role of nutritional management in critically ill pediatric patients.
Data extraction
If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, adequate information provided, and assessment measures defined.
Data synthesis
Comparisons were made by structured review with the results tabulated.
In total, 50 studies indicated that ICU patients who present with malnutrition or at a high probability of developing malnutrition during their hospital stay and those who are not expected to be on a full oral diet within 3 days should receive specialized enteral and/or parenteral nutritional support. Feeding should be started early within the first 24–48 h to facilitate diet tolerance and reduce the risk of intestinal barrier dysfunction and infections.
This review found that critically ill pediatric patients are at risk of malnutrition. Enteral nutrition is the preferred mode of nutrition and should be used whenever possible. Total parental nutrition is used only if the gastrointestinal tract is unable to meet the nutritional requirements for 1–3 days in infants and 4–5 days in children and adolescents.

Keywords: enteral nutrition, malnutrition, nutritional management, parenteral nutrition

How to cite this article:
Elshafie AM, El-Lahony DM, Omar ZA, Bahbah WA, Ghetas HR. Nutrition in critically Ill pediatric patients: a systemic review. Menoufia Med J 2019;32:812-7

How to cite this URL:
Elshafie AM, El-Lahony DM, Omar ZA, Bahbah WA, Ghetas HR. Nutrition in critically Ill pediatric patients: a systemic review. Menoufia Med J [serial online] 2019 [cited 2020 May 27];32:812-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/812/268814

  Introduction Top

Critical illness is any disease process which causes physiological instability leading to disability or death within minutes or hours [1]. Critically ill pediatric patients have complex nutritional needs and require intensive nutritional support. As part of the metabolic response to injury, resting energy expenditure may be raised, leading to extensive catabolism, hyperglycemia, progressive lean body mass loss, changes in serum trace element levels, fluid retention, and reduced synthesis of visceral proteins such as albumin. Contributing toPoorer ou tcome is the high prevalence of malnutrition (40%) in pediatric ICU patients, as reported by previous studies [2]. Overall, the goal of feeding in pediatric ICU (PICU) patients is to provide nutrition support to those who need it, consistent with their medical condition, nutritional status, metabolic capability, and available route of administration [3]. Enteral nutrition (EN) in critically ill patient with a functioning gastrointestin al (GI) tract should be the preferred mode of nutrition if tolerated to maintain physiologic and functional integrity of gut mucosa [4]. Parenteral nutrition (PN) involves the infusion of mixture of amino acids, carbohydrates, and fat, as well as electrolytes and micronutrients. Sometimes PN is needed to supplement insufficient EN; total PN means that the infusion provides the patient's complete nutritional requirements [5]. Transition from PN to EN should be done through appropriate minimal entera l feeds given in conjunction with PN wherever possible to prevent gut atrophy and encourage gut adaptation, as well as reduce the risk of PN [6]. So, this present study aims to review the different types of nutrition in critically ill pediatric patients.

  Patients and Methods Top

Search strategy

We reviewed papers on the influence of different types of nutrition in critically ill pediatric patients from Medline databases, such PubMed, Medscape, and Science Direct, and materials available in the Internet. We used critically ill patients/different types of nutrition/nutritional management in critically ill pediatric patient/length of stay in PICU/mortality rate in PICU as search terms. In addition, we examined references from the specialist databases EMF-Portal (http://www.emf-portal.de), reference lists in relevant publications, and published reports about nutrition in critical illness. The search was performed in the electronic databases from 2001 to 2014.

Study selection

All the studies were independently assessed for inclusion. They were included if they fulfilled the following criteria: published in English language, published in peer-reviewed journals, studied critically ill pediatric patients, studied different types of nutritional management in critically ill pediatric patients, length of stay in PICU, and mortality rate in PICU.

If a study had several publications on certain aspects, we used the latest publication giving the most relevant data.

Data extraction

If the studies did not fulfill the aforementioned criteria, they were excluded, such as nutrition management in noncritically ill patients, surveys about symptoms and health concerns without exposure assessment, report without peer-review, not within national research program, letters/comments/editorials/news, and studies not focused on exposure in noncritical illness and critical illness in adult patients.

Quality assessment

The quality of all the studies was assessed. Important factors included study design, attainment of ethical approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis made in addition to an explanation of missing data.

Data synthesis

A structured systematic review was performed with the results tabulated.

  Results Top

Study selection and characteristics

In total, 150 potentially relevant publications were identified, and 100 articles were excluded as they did not meet our inclusion criteria. Therefore, 50 studies were included in the review as they were deemed eligible by fulfilling the inclusion criteria. Most of the studies examined malnutrition and the role of different types of nutrition in critically ill pediatric patients.

Anthropometric changes during pediatric critical illness

Regarding anthropometric changes during pediatric critical illness, several studies are presented in [Table 1]. Two cohort studies [7],[8] observed a correlation between energy deficit and deterioration in anthropometric parameters in a mixed population of critically ill children, and one cohort study [9] reported 65% prevalence of malnutrition on admission with increased mortality in this group. Another four retrospective cohort studies [10],[11],[12],[13] examined the performance of estimated energy needs in relation to measure resting energy expenditure in critically ill children.
Table 1: Anthropometric changes during pediatric critical illness

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Enteral nutrition in critically ill patient

Regarding enteral nutrition in critically ill patient, several studies presented in [Table 2] described nutritional support to critically ill patients. One literature review [14] defined enteral nutrition as a way of provision of nutrition into the gastrointestinal tract for the patients unable to otherwise meet nutrient requirements by oral route. There was another cohort study [15] that reported better tolerance in critically ill children receiving early (<24 h after PICU admission). than children feeding late (after 24 h) postpyloric nutrition. Another two RCTs [16],[17] compared different route of EN feeding: one study [16] comparing gastric versus small bowel continuous tube feeds showed no significant difference, and the other study [17] comparing gastric EN administered either continuously or every 2 h showed tolerance to EN was similar. There were three cohort studies [18],[19],[20] that reported inability to achieve daily caloric goal in critically ill children, and the most common reasons for suboptimal enteral nutrient delivery are fluid restriction, interruption to EN, and EN intolerance owing to hemodynamic instability. Regarding the effect of immune-enhancing formula, there were eight trails [21],[22],[23],[24],[25],[26],[27],[28] comparing the role of immune-enhancing EN containing glutamine, arginine, omega-3 fatty acids, and antioxidants with standard age-appropriate formula; they did not show any clinically important outcomes. There were another four retrospective studies [29],[30],[31],[32] regarding presence of specialized nu trition support team in the PICU, and aggressive feeding protocols may enhance the overall delivery of nutrition with shorter time to achieve nutritional support and increase EN with decrease in the use of PN.
Table 2: Enteral nutrition in critically ill patient

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Parenteral nutrition

Regarding PN in critical illness, several studies presented in [Table 3] described parental nutrition. One literature review [33] defined PN as the feeding of the patients intravenously by passing over the usual process of eating and digestion. In a randomized study [34] involving 300 patients undergoing major surgery, the patients received continuous total parental nutrition or exclusively glucose (250–300 g/day) intravenous administration for 14 days. Those on parental nutrition had 10 times less mortality than those on glucose. Regarding the benefits of PN, four meta-analysis studies [35],[36],[37],[38] demonstrated the benefits of PN during PICU admission. An unblended study [39] showed intravenous fish oil supplementation had favorable effects on survival, infection rate, and length of stay, and another four studies [40],[41],[42],[43] described that administration of PN supplemented with fish oil-enriched lipid emulsion showed no significant difference in term of mortality. Six trails, one post-hoc analysis and five RCTs [44],[45],[46],[47],[48],[49], investigated the effect of different dose and composition of PN in critically ill children treated in PICU. Of these six studies, four studies investigated infant after cardiac surgery and two included children with sepsis or after other major surgery or burns, respectively.
Table 3: Parenteral nutrition

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  Discussion Top

Clinical instability and poor nutritional status in critically ill children have been reported as barrier to providing optimal nutrition [50]. Prevalence of malnutrition (15–65%) on admission is related to increased mortality in this group, and on follow-up, a significant portion of these children had further deterioration in nutrition status [9]. Stress or activity correction factors have been traditionally factored into basal energy requirement estimates to adjust for the nature of illness, of its severity, and the activity level of hospitalized patients [22]. Patients at high risk for metabolic alterations such as underweight patient (BMI<fifth percentile for age), patients in need for muscle relaxants for more than 7 days, patients having neurologic trauma such as traumatic, hypoxic, and/or ischemic with evidence of dysautonomia, oncologic diagnoses including children with stem cell or bone marrow transplant, children with thermal injury, children requiring mechanical ventilator support for more than 7 days, and children suspected to be severely hypermetabolic, such as status epilepticus, hyperthermia, systemic inflammatory response syndrome, and dysautonomia storms, or hypometabolic, such as hypothermia, hypothyroidism, phenobarbital, or midazolam coma [51]. Nutrition management includes both EN and PN. For critically ill children with a functioning GI tract, the enteral route is preferable to PN. EN is physiologic and has been shown to be more cost effective without the added risk of nosocomial infection inherent with PN [52]. Critically ill children receiving early feeding (<24 h after PICU admission) reported better tolerance than children feeding late (after 24 h) postpyloric nutrition [35]. GI symptoms are the most common complication of EN including aspiration, diarrhea, constipation, vomiting, and abdominal distention. These may be minimized by selection of the appropriate enteral formula and mode of delivery, gradual introduction of the feed with monitoring of residual gastric volumes [53]. About total PN is provision of nutrition for metabolic requirements and growth through the parenteral route [46]. The indications for PN in children are similar to the indications in adults, that is, if the GI tract cannot be used as a route of administration for nutrition, parenteral nutrition may be indicated. One big difference versus adults is that due to fewer body stores and a higher caloric daily requirement, children are started on hyperalimentation sooner than adults [54]. Catheter-related sepsis is one of the most serious complications. Incidence of catheter-related sepsis is ~5%, and it is documented that any fever in the absence of an obvious focus of infection must be attributed to catheter-related sepsis until proved otherwise. Added that the use of antacids and third-generation cephalosporins and a delay in enteral feeding are encourage bacterial colonization [55] lipid-related complications including lipid intolerance, increased free bilirubin concentrations, impaired pul monary function, or increased risk for developing chronic lung disease and interference with immune and platelet function [56]. The most serious and significant life-threatening complication nowadays continues to be parenteral nutrition-associated cholestasis. During total parental nutrition infusion, a minimal amount of enteral feeds should be given to patients whenever possible and increased gradually while decreasing total PN. Aba-Sinden and Bollinger [57] recommended that parental nutrition may be stopped when the infant is tolerating at least 100 cm 3/kg/day of enteral feedings or is receiving up to 25 cm 3/kg/day of total parental nutrition [58].

  Conclusion Top

EN should be used whenever possible. Total PN is used only if the GI tract is unable to meet the nutritional requirements for 1–3 days in infants and 4–5 days in children and adolescents.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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